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Medical futility as an action guide in neonatal end-of-life decisions

Sidler, Daniel (2004-03)

Thesis (MPhil)--University of Stellenbosch, 2004.

Thesis

ENGLISH ABSTRACT: This thesis discusses the value of medical futility as an action guide for neonatal endof-
life decisions. The concept is contextualized within the narrative of medical
progress, the uncertainty of medical prognostication and the difficulty of just resource
allocation, within the unique African situation where children are worse off today
than they were at the beginning of the last century. parties actively engage in an interactive deliberation for a plan of action. Both parties
ought to accept moral responsibility. Such a model of deliberation has the added
advantage of transcending the limitations of the participants to arrive at a higher-level
solution, which is considered more than just a consensus.
It has been argued that medical progress has obscured the basic need for human
compassion for the dying and for their loved ones. The literature furthermore reports
that the quality of end-of-life care is unsatisfactory for both patients and their
families. It is within this context that the concept of medical futility is positioned as a
useful action guide.
As we do not have the luxury of withdrawing from the responsibility to engage in the
deliberation of end-of-life decisions, such responsibility demands an increasing
awareness of ethical dilemmas and a model of medical training where
communication, conflict-resolution, inclusive history taking, with assessment of
patient values and preferences, is focussed on. The capacity for empathetic care has to
be emphasized as an integral part of such approach. Finally, in this thesis, the concept
of medical futility is tested and applied to clinical case scenarios.
It is argued that the traditional medical paradigm, with its justification of an 'all out
war' against disease and death, in order to achieve utopia for all, is outdated. Death in
the neonatal intensive care unit is increasingly attributed to end-of-life decisions.
Futile treatment could be considered a waste of scarce resources, contradicting the
principle of nonmaleficence and justice, particularly in an African context.
The ongoing confidence in, and uncritical submission to the technological progress in
medicine is understood as a defence and coping mechanism against the backdrop of
the experience of life's fragility, suffering and the inevitability of death.
Such uncritical acceptance of the technological imperative could lead to a harmful
fallacy that cure is effected by prolonging life at all cost. What actually occurs,
instead, is the prolongation of the dying process, increasing suffering for all parties
involved.
The historical development of the concept of medical futility is discussed,
highlighting its applicability to the paradigmatic scenario of cardio-pulmonary
resuscitation. Particular attention is given to ways in which the concept could
endanger patient-autonomy by allowing physicians to make unilateral, paternalistic
decisions.
It is argued that the informative model of the patient-physician relationship, where the
physician's role is to disclose information in order for the patient to indicate her
preferences, ought to be replaced by a more adequate deliberative model, where both